LAUSR

A 55-year-old male, known case of periampullary carcinoma was posted for Whipple’s surgery. He had a right-sided ventricular pacing wire inserted through the right subclavian and brachiocephalic vein [Figure 1a]. In the operation theatre, the electrocardiogram, non-invasive blood pressure, SPO2, EtCO2 were connected and left-sided central venous cannulation was attempted using ultrasonography guidance under local anaesthesia. The patient had a history of unsuccessful blind left internal jugular vein (IJV) cannulation. The left IJV was chosen as the patient had right-sided ventricular pacing and we thought of putting the catheter tip at the junction of the right and left brachiocephalic veins without disturbing the right ventricular pacing wire. After puncture, a guidewire was inserted and monitored under fluoroscopy. The tip of the guidewire could not be pushed towards left brachiocephalic vein and superior vena cava (SVC), but could be seen going towards the left paracardiac region. To exclude a perforation and extraluminal migration of guidewire into the mediastinum, a contrast study using a 5F multipurpose angiographic catheter was performed with the help of a cardiologist. There was opacification of a tubular channel in the left paracardiac region draining into the left coronary sinus without opacification of the left brachiocephalic vein and SVC [Figure 1b], suggesting persistent left-sided SVC (PLSVC). A small vein communicating left SVC with right SVC [Figure 1b] was also seen. Subsequently, we abandoned the procedure and left femoral venous route was used successfully for central venous catheterisation.